Avulsion of the
pectoralis major tendon
JAIN LIU,* MD, JIUNN-JER WU,*† MD, CHENG-YEN CHANG,‡ MD, YI-HONG CHOU,‡ MD, AND WAI-HEE LO,* MD
From the
Departments of *Orthopedics and Traumatology, and the Department of ‡Radiology, Veterans General Hospital, Taipei, Taiwan, Republic of China the chest with shoulder splint and swathe for 4 weeks. Protected range of motion of the left shoulder was started during the 5th week. External rotation was not allowed until 12 weeks after surgery. At 4-month followup, the patient had full, painless range of motion and had begun weight training. The Cybex muscle test performed at that time showed much improvement in adduction strength (Table 1). The patient was very satisfied with the results.
Avulsion of the pectoralis major tendon is a rare injury, with only about 20 cases reported in the literature. We report a case of partial avulsion of the pectoralis major tendon. Cybex isokinetic muscle testing, computed tomography, and ultrasonography were used in the diagnosis and are correlated with the operative findings. Direct repair was performed 1 year after injury, and then the patient began a good rehabilitation program. An excellent result was obtained and is clearly shown by the Cybex II muscle results.
CASE REPORT DISCUSSION A 27-year-old male weight lifter reported that about 1 year before presentation he was trying to lift a 100 kg weight without warming up when he felt a sudden severe pain in his left shoulder. He was only able to move his left arm after much effort. The next day, he noticed a bulge in his left axilla and an ecchymotic area on the medial aspect of his left upper arm. He thought the injury was a strain and chose massage therapy. The swelling gradually subsided, but weakness and pain continued to persist, even while doing pushup exercises. On examination, the patient was noted to be a strong, muscular man, but his left axillary fold was not apparent (Fig. 1). He had weak adduction and internal rotation of the left arm, but full range of motion of the shoulder. Cybex isokinetic muscle testing was performed and revealed weak adduction of the left shoulder (Table 1). Radiographs showed no bone injury. A diagnosis of ruptured pectoralis major tendon was made and confirmed by computed tomography (Fig. 2) and ultrasonography (Fig. 3). Surgery was performed using the deltopectoral approach. We noted that only the inferior three-fourths of the tendon was avulsed from its insertion on the humerus (Fig. 4. The tendon was repaired with nonabsorbable, interrupted heavy sutures attaching it to the clavipectoral fascia. The arm was then immobilized in adduction and internal rotation against
Rupture of the pectoralis major muscle was first described by Patissier,’ and is rare. There are only about 60 cases reported in the literature,l~3-s of which only about 20 in 1822
t Address correspondence and reprint requests to: Jiunn-Jer Wu, MD, Department of Orthopedics and Traumatology, Veteran’s General Hospital, Taipei, Taiwan, Republic of China.
1. Frontal view of torso. The marked left anterior axillary fold is apparent (arrow).
Figure 366
thinning of
the
367 TABLE 1
Cybex II isokinetic muscle
test
results
Figure 2. Serial axial scans of computerized tomography of the upper chest show disruption of the tendon (arrows) and atrophy of the left pectoralis major muscle. Only a few torn tendon fibers remained.
Figure 3. Ultrasonography of both sides of the pectoralis major muscle. A, transverse section of the left side shows thinning and uneven echogenicity (arrow) of the muscle, which was caused by degeneration and fibrosis. B, sagittal section showing irregular echogenicity over the distal-inferior portion (arrow) of the left pectoralis major indicates torn region.
avulsions of the pectoralis major tendon.3-6 Two-thirds of these cases were incomplete avulsions. The symptoms of pectoralis major avulsion include a sudden severe pain in the arm and shoulder at the time of injury, with or without a &dquo;snap&dquo;; painful limitation of motion ; swelling and ecchymosis; and weakness. The physical findings are a thin anterior axillary fold, or even a sulcus; muscle bulging; and weakness in adduction and internal rotation of the arm. Because of the rarity of this condition, the above symptoms and signs might be ignored by general were
practitioners. The most common mechanisms of avulsion are weight lifting and attempting to grasp something to prevent a fall.2,5,6 The reported causes of rupture of the pectoralis major muscle belly are direct trauma, birth trauma, invol-
untary contraction, and spontaneous rupture because of
degenerative change. We agree with other authors that surgical repair of the avulsed tendon ensures the best results. Some authors sutured the tendon to the periosteum5 or the remaining stump’ without drilling the bone and obtained excellent results. In
Figure 4. Intraoperative photo shows the inferior three-fourths of the tendon is torn (arrow).
368
general, however, most authors suggest that suturing to the proximal humerus through drilled holes, with or without pullout wire,2,5,6 or through an osseous window with a &dquo;trapdoor technique,&dquo; were more reliable methods.’ In this case, we
a
found that
we were
able to attach the avulsed tendon to
strong clavipectoral fascia that could hold the sutures
securely, which also gave satisfactory results. The pectoralis major is the most important adductor and internal rotator of the shoulder and cosmetically forms the anterior wall of the axilla. Surgical repair is essential to restore complete function and contour, especially in young athletes. Conservative treatment can also yield satisfactory
CONCLUSIONS We report a case of a patient who delayed seeking treatment for partial avulsion of the pectoralis major tendon. The tomograms and ultrasonographs are presented in detail and correlate with the operative findings. Direct repair and rehabilitation may provide an excellent functional outcome. The improvement is clearly shown by the Cybex isokinetic muscle test results.
REFERENCES
results.’ Even though the patient had the injury for about 1 year before seeking repair, he was still able to obtain excellent results after treatment. This is probably because of the partial avulsion, which may have prevented full retraction of the muscle mass,’ and the good rehabilitation program. Modern diagnostic tools can aid in confirming the diagnosis of these tears. This report is the first to show the avulsion on computed tomography and ultrasonography, with good correlation at surgery. We also compared, as did Krezler and Richardson,2 preoperative and postoperative isokinetic muscle strength.
1. Kawashima M, Sato M, Torisu T, et al: Rupture of the pectoralis major: Report of two cases. Clin Orthop 109: 115-119, 1975 2. Kretzler HH, Richardson AB: Rupture of the pectoralis major muscle. Am J Sports Med 17: 453-458, 1989 3. Lindenbaum BL: Delayed repair of a ruptured pectoralis major muscle. Clin
120-121, 1975 Orthop 109: Manjarris J, Gershuni DH, Moitoza
J: Rupture of the pectoralis major tendon. J Trauma 25: 810-811, 1985 5. McEntire JE, Hess WE, Coleman SS: Rupture of the pectoralis major muscle : A report of eleven injuries and review of fifty-six. J Bone Joint Surg 54A: 1040-1046, 1972 6. Park JY, Espinella JL: Rupture of pectoralis major muscle : A case report and review of literature. J Bone Joint Surg 52A: 577-581, 1970 7. Patissier P: Traite des Maladies Artisans. Paris, 1822, pp 162-164 4.
pectoralis major tendon
JAIN LIU,* MD, JIUNN-JER WU,*† MD, CHENG-YEN CHANG,‡ MD, YI-HONG CHOU,‡ MD, AND WAI-HEE LO,* MD
From the
Departments of *Orthopedics and Traumatology, and the Department of ‡Radiology, Veterans General Hospital, Taipei, Taiwan, Republic of China the chest with shoulder splint and swathe for 4 weeks. Protected range of motion of the left shoulder was started during the 5th week. External rotation was not allowed until 12 weeks after surgery. At 4-month followup, the patient had full, painless range of motion and had begun weight training. The Cybex muscle test performed at that time showed much improvement in adduction strength (Table 1). The patient was very satisfied with the results.
Avulsion of the pectoralis major tendon is a rare injury, with only about 20 cases reported in the literature. We report a case of partial avulsion of the pectoralis major tendon. Cybex isokinetic muscle testing, computed tomography, and ultrasonography were used in the diagnosis and are correlated with the operative findings. Direct repair was performed 1 year after injury, and then the patient began a good rehabilitation program. An excellent result was obtained and is clearly shown by the Cybex II muscle results.
CASE REPORT DISCUSSION A 27-year-old male weight lifter reported that about 1 year before presentation he was trying to lift a 100 kg weight without warming up when he felt a sudden severe pain in his left shoulder. He was only able to move his left arm after much effort. The next day, he noticed a bulge in his left axilla and an ecchymotic area on the medial aspect of his left upper arm. He thought the injury was a strain and chose massage therapy. The swelling gradually subsided, but weakness and pain continued to persist, even while doing pushup exercises. On examination, the patient was noted to be a strong, muscular man, but his left axillary fold was not apparent (Fig. 1). He had weak adduction and internal rotation of the left arm, but full range of motion of the shoulder. Cybex isokinetic muscle testing was performed and revealed weak adduction of the left shoulder (Table 1). Radiographs showed no bone injury. A diagnosis of ruptured pectoralis major tendon was made and confirmed by computed tomography (Fig. 2) and ultrasonography (Fig. 3). Surgery was performed using the deltopectoral approach. We noted that only the inferior three-fourths of the tendon was avulsed from its insertion on the humerus (Fig. 4. The tendon was repaired with nonabsorbable, interrupted heavy sutures attaching it to the clavipectoral fascia. The arm was then immobilized in adduction and internal rotation against
Rupture of the pectoralis major muscle was first described by Patissier,’ and is rare. There are only about 60 cases reported in the literature,l~3-s of which only about 20 in 1822
t Address correspondence and reprint requests to: Jiunn-Jer Wu, MD, Department of Orthopedics and Traumatology, Veteran’s General Hospital, Taipei, Taiwan, Republic of China.
1. Frontal view of torso. The marked left anterior axillary fold is apparent (arrow).
Figure 366
thinning of
the
367 TABLE 1
Cybex II isokinetic muscle
test
results
Figure 2. Serial axial scans of computerized tomography of the upper chest show disruption of the tendon (arrows) and atrophy of the left pectoralis major muscle. Only a few torn tendon fibers remained.
Figure 3. Ultrasonography of both sides of the pectoralis major muscle. A, transverse section of the left side shows thinning and uneven echogenicity (arrow) of the muscle, which was caused by degeneration and fibrosis. B, sagittal section showing irregular echogenicity over the distal-inferior portion (arrow) of the left pectoralis major indicates torn region.
avulsions of the pectoralis major tendon.3-6 Two-thirds of these cases were incomplete avulsions. The symptoms of pectoralis major avulsion include a sudden severe pain in the arm and shoulder at the time of injury, with or without a &dquo;snap&dquo;; painful limitation of motion ; swelling and ecchymosis; and weakness. The physical findings are a thin anterior axillary fold, or even a sulcus; muscle bulging; and weakness in adduction and internal rotation of the arm. Because of the rarity of this condition, the above symptoms and signs might be ignored by general were
practitioners. The most common mechanisms of avulsion are weight lifting and attempting to grasp something to prevent a fall.2,5,6 The reported causes of rupture of the pectoralis major muscle belly are direct trauma, birth trauma, invol-
untary contraction, and spontaneous rupture because of
degenerative change. We agree with other authors that surgical repair of the avulsed tendon ensures the best results. Some authors sutured the tendon to the periosteum5 or the remaining stump’ without drilling the bone and obtained excellent results. In
Figure 4. Intraoperative photo shows the inferior three-fourths of the tendon is torn (arrow).
368
general, however, most authors suggest that suturing to the proximal humerus through drilled holes, with or without pullout wire,2,5,6 or through an osseous window with a &dquo;trapdoor technique,&dquo; were more reliable methods.’ In this case, we
a
found that
we were
able to attach the avulsed tendon to
strong clavipectoral fascia that could hold the sutures
securely, which also gave satisfactory results. The pectoralis major is the most important adductor and internal rotator of the shoulder and cosmetically forms the anterior wall of the axilla. Surgical repair is essential to restore complete function and contour, especially in young athletes. Conservative treatment can also yield satisfactory
CONCLUSIONS We report a case of a patient who delayed seeking treatment for partial avulsion of the pectoralis major tendon. The tomograms and ultrasonographs are presented in detail and correlate with the operative findings. Direct repair and rehabilitation may provide an excellent functional outcome. The improvement is clearly shown by the Cybex isokinetic muscle test results.
REFERENCES
results.’ Even though the patient had the injury for about 1 year before seeking repair, he was still able to obtain excellent results after treatment. This is probably because of the partial avulsion, which may have prevented full retraction of the muscle mass,’ and the good rehabilitation program. Modern diagnostic tools can aid in confirming the diagnosis of these tears. This report is the first to show the avulsion on computed tomography and ultrasonography, with good correlation at surgery. We also compared, as did Krezler and Richardson,2 preoperative and postoperative isokinetic muscle strength.
1. Kawashima M, Sato M, Torisu T, et al: Rupture of the pectoralis major: Report of two cases. Clin Orthop 109: 115-119, 1975 2. Kretzler HH, Richardson AB: Rupture of the pectoralis major muscle. Am J Sports Med 17: 453-458, 1989 3. Lindenbaum BL: Delayed repair of a ruptured pectoralis major muscle. Clin
120-121, 1975 Orthop 109: Manjarris J, Gershuni DH, Moitoza
J: Rupture of the pectoralis major tendon. J Trauma 25: 810-811, 1985 5. McEntire JE, Hess WE, Coleman SS: Rupture of the pectoralis major muscle : A report of eleven injuries and review of fifty-six. J Bone Joint Surg 54A: 1040-1046, 1972 6. Park JY, Espinella JL: Rupture of pectoralis major muscle : A case report and review of literature. J Bone Joint Surg 52A: 577-581, 1970 7. Patissier P: Traite des Maladies Artisans. Paris, 1822, pp 162-164 4.
